CHAPTERS 26 &42 TANYA COMER, RN BSN

VITAL SIGNS Vital signs reflect the function of three body processes essential for life Regulation of body temperature Breathing Heart function The four vital signs of body function are: Temperature Pulse Respirations Blood pressure Some agencies consider “pain” to be the 5 th vital sign

MEASURING VITAL SIGNS AND REPORTING A person’s vital signs vary within certain limits Vital signs Are measured to detect changes in normal body function Tell about treatment response Often signal life-threatening events Are part of the assessment step in the nursing process

MEASURING VITAL SIGNS AND REPORTING (CONT) Vital signs are measured During physical exams When the person is admitted to the health care agency Before and after surgery, complex procedures and diagnostic tests After some care measure (ambulation) After a a fall or other injury When drugs effect the respiratory or circulatory system When a person c/o dizziness, pain, light-headedness, feeling faint, short of breath, or not feeling well

MEASURING VITAL SIGNS AND REPORTING (CONT) Vital signs show even minor changes in the persons condition Accuracy is essential when you measure, record, and report vital signs Take vital signs with the person at rest, lying or sitting unless otherwise ordered Report the following at once Any vital sign that has changed from the prior measurement Vital signs above normal range Vital signs below normal range

BODY TEMPERATURE Body temperature is a balance between amount of heat produced and amount lost by the body Thermometers measure temperature Temperature sites include Mouth, rectum, axilla (underarm), tympanic membrane (ear), and temporal artery (forehead) Always report temperatures that are above or below the normal range

BODY TEMPERATURE (CONT) Types of thermometers used Glass thermometers Standard electronic thermometers Digital Disposable oral thermometers Temperature sensitive tape Pacifier thermometer Taking temperature The nurse and care plan tell you when to take the person’s temperature, what site to use and what thermometer to use.

PULSE A pulse is felt every time the heart beats The pulse is the beat of the heart felt at an artery as a wave of blood passes trough the artery Pulse sites Temporal, carotid, brachial, radial, femoral, popliteal Posterior tibial and dorsalis pedis pulses are on each side of the body Radial pulse is used most often Carotid pulse is taken during CPR and other emergencies The apical pulse is felt over the heat This pulse is taken with a stethoscope

PULSE A stethoscope is an instrument used to listen to sounds produced by the heart, lungs, and other body organs. It is used to take apical pulses and blood pressures The devices makes sounds louder and easy to hear To use a stethoscope Wipe the earpieces and diaphragm with antiseptic Place the earpiece tips in your ears Tap the diaphragm gently Please the diaphragm over the pulse site Prevent noise

PULSE The pulse rate is the number of heat beats or pulses felt in 1 minute The adult pulse rate is between beats per minute. Report abnormal pulses to the nurse at once Tachycardia is a heart rate of more than 100 beats per min Bradycardia is a heart rate of less than 60 beats per min

PULSE Rhythm and force of the pulse Pulse and rhythm should be regular (a pattern with the same interval between beats) Ann irregular pulse occurs when the beats are not evenly spaced or beats are skipped Force relates to pulse strength A forceful pulse is described as strong, or bounding Electronic blood pressure equipment can also count pulses Some show if the pulse is regular or irregular You need to feel the pulse to determine the force

PULSE You will take radial, apical and apical-radial pulses You must accurately Count Report and record The radial pulse is used for routine vital signs Count the pulse for 30 seconds and multiply by 2 Of the pulse is irregular count it for a full minute

BLOOD PRESSURE Blood pressure is the amount of force exerted against the walls of an artery by the blood Blood pressure is controlled by The force of heart contractions The amount of blood pumped with each heart beat How easily the blood flows through the blood vessels Systole is the period of heart muscle contraction Diastole is the period of heart muscle relaxation

BLOOD PRESSURE Systolic pressure- the pressure in the arteries when the heart contracts Diastolic pressure- the pressure in the arteries when the heart is at rest Blood pressure is measured in millimeters of mercury (mmHg) Blood pressure normal ranges Systolic pressure – 90 mm Hg or higher but lower than 120 mm Hg Diastolic pressure -60 mm Hg or higher but lower than 80 mm Hg

CARDIOVASCULAR DISORDERS The circulatory system delivers blood to the body’s cells. Problems that occure in the heart or blood vessels include Hypertension Coronary artery disease Angina Myocardial infarction Heart failure Dysrhythmias

CARDIOVASCULAR DISORDERS (CONT) With hypertension, the resting blood pressure is too high Systolic pressure = 140 mm Hg or higher Diastolic pressure = 90 mm Hg or higher Pre-hypertension will likely develop into hypertension in the future Systolic pressure = mm Hg or Diastolic pressure = mm Hg Causes include Narrowed blood vessels, kidney disorders, head injuries, some pregnancy problems, and adrenal glad tumors

CARDIOVASCULAR DISORDERS (CONT) Hypertension can lead to Stroke (CVA) Hardening of the arteries Heart attack heart failure Kidney failure blindness Life-style changes can lower blood pressure certain drugs can lower blood pressure

RESPIRATORY DISORDERS The respiratory system brings oxygen into the lungs and removes carbon dioxide from the body Respiratory disorders that interfere with this function and threaten life include COPD Chronic bronchitis Asthma Sleep apnea Influenza Pneumonia tuberculosis

LYMPHATIC DISORDERS The lymphatic system drains extra fluid from the tissues, helps fight infection and absorbs and transports fats Lymphatic disorders that affect these functions include Lymphedema lymphoma